SPECIAL CONSULTANT AGREEMENT FORM PRINT FORM

Date
Appt:
SPECIAL CONSULTANT AGREEMENT FORM
New
Extended
PART I – GENERAL INFORMATION
Consultant:
Address:
EMPLID:
Work Phone:
Home Phone:
Department:
Check All
That Apply:
Cell Phone:
Supervisor/Ext:
Contact Name/Ext:
Current CSU Stanislaus Employee
Current CSU Employee
Campus: Dormitory (D)
Former CSU Stanislaus Employee
CalPERS/STRS Member
New Employee to CSU Stanislaus
PERS Retiree (Retired Annuint)
PART II - COMPLETE FOR CURRENT CSU AND CSU STANISLAUS EMPLOYEES ONLY
Select Primary CSU/CSU Stanislaus Position Status: Part-Time If Part Time Enter Percentage:
Will this appointment result in more than 125% employment within the CSU system? Yes
Is this appointment outside normal CSU work hours? Yes
If “No” complete the following:
Is appointee taking vacation to complete this assignment? Yes
No
No
No
If Yes, attach Absence Request Form 634
No
Is appointee adjusting work schedule to complete this assignment? Yes
If Yes, attach adjusted work schedule
PART III - SPECIFIC DESCRIPTION OF DUTIES
PART IV - PAYMENT INFORMATION
Beginning Date:
Ending Date:
Daily Rate:
For more information visit the CSU Salary Schedule
Number of work days not to exceed: _______________ Maximum Funding Authorized:______________
FUNDING SOURCE
DEPT ID
FUND
PROGRAM (If Required)
PROJECT (If Required)
601302
Trust (TM)
BUDGET USE ONLY:
ACCOUNT
CMS#:
PIMS#:
PART V – AUTHORIZED SIGNATURES
I have reviewed the special consultant guidelines. This appointment will be consistent with the appropriate CSU guidelines and collective
bargaining agreement.
Dean/Dept Head:
Faculty Affairs/
Human Resources:
Signature:
Date:
Signature:
Date:
Budget:
Signature:
Date:
Provost/
Vice President:
Signature:
Date:
Subject to the conditions stated in the Guidelines for Special Consultant Agreements, I agree to perform the duties described above within the
time period indicated. If I am a new or returning employee, I understand I will need to provide identification documents and complete certain
forms prior to the effective date of this appointment. In addition I understand that no payment will be made without an approved Request for
Special Consultant Payment form submitted to the Payroll Office for each pay period worked. I certify this Special Consultant assignment will not
conflict with my regular CSU Stanislaus employment, if any.
Date:
Consultant Signature:
HR Form# 18 Revised 06/11 CSUSTANPECCONSFORM
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